tasc_mental_health_roundtable_brief

Mental Health and Covid-19 TASC is an independent think-tank whose core focus is addressing inequality and sustaining democracy

Roundtable Briefing Document: 24 November 2020

Mental health and inequality: assessing the impact of the pandemic TASC Roundtable Discussion – Tuesday 24 November – 11am ‘Good mental health is critical to the functioning of society at the best of times.’ (United Nations, 2020) ‘The Cinderella of the Health Services’ (Mental Health Reform, 2018) ‘Support everyone on the basis of need and not just on the capacity to pay’ (EAPN, 2020) ‘Just 23.7% of participants agreed or strongly agreed that “the Government has done enough to address the impact of the COVID-19 pandemic on mental health”’ (Mental Health Reform, 2020) Even when the pandemic is brought under control, grief, anxiety and depression will still be prevalent. (United Nations, 2020). Mental health services need to be equipped to handle the aftermath of COVID-19 from post-traumatic stress to social anxiety. They also need to figure in resilience strategies related to climate change, digital transformation and loss of jobs, precarity of income and housing, and other external shocks and trends.

The UN recommends a significant investment increase in psychological supports, emergency mental healthcare and recovery services to build mental health services for the future (United Nations, 2020; C19 PRC & Mental Health Reform, 2020). Dévora Kestel, Director of the Department of Mental Health and Substance Use at WHO, commented in May that in order to build a mental health system ‘fit for purpose’, it would mean “developing and funding national plans that shift care away from institutions to community services, ensuring coverage for mental health conditions in health insurance packages and building the human resource capacity to deliver quality mental health and social care in the community” 1 (2020).Social inclusion ought to be at the forefront of this discussion on mental health services to address resource allocation, distribution, and participation in society - including marginalised groups.

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https://www.who.int/news/item/14-05-2020-substantial-investment-needed-to-avert-mental-health-crisis

This round table has two main objectives: 1. To review the effects of the pandemic, lockdowns, and economic crisis on mental health; especially among lower income and vulnerable groups, but also amongst the wider population in order to gauge the scale of the crisis and existing and future demand.

2. To discuss needed policy reform and investment, especially to ensure access for the most at-risk groups.

The principal questions we would like to address include the following: How has the current crisis exacerbated existing problems regarding access to mental health services?

Which services have been most in demand and why during the crisis? What needs to be done going forward to make sure demand is met?

To what degree does income affect access to services?

Which segments of the population have needed support the most during this period? What has their experience been in trying to access services?

Does the government need a different strategy going forward? Is communication and coordination between departments an obstacle to effective delivery of services?

How can civil society organisations advocate effectively for greater investment?

Can investment in mental health services reduce income inequality?

Can the link between investment in mental health services and economic and social resilience be better articulated?

Investment in Mental Health Services Pre-Pandemic Since 2012, the Irish mental health budget has increased by almost 40% (Dáil Eireann, 2019).

However, implementing the “Vision for Change” has been slow. The expansion of services has not met rising demand. As of December 2017, there were over 8,000 people on the waiting list for primary care psychology. Out of these, around 30% of people were waiting for more than a year (The Irish Times, 2018).2 Medical health supports are also highly understaffed, with the Psychological Society of Ireland in September 2019 reporting a waiting list of 6,300 children for primary-care assessments and a waiting list of 3,345 adults for counselling (McDaid, 2020).

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The Irish Times view on mental health funding: a chance to improve’

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Referral rates to Child and Adolescent Mental Health Services (CAMHS) have increased by 63% from 2010 to 2016, some waiting over a year to be seen. There has likewise been a 28.7% increase in those disabled by a mental health difficulty between 2011 and 2016, yet the Irish budget cannot meet standards to adequately invest or develop this sector (Mental Health Reform, 2018).

In comparison, in 2019 the UK government legislated to invest an extra 20 billion pounds over five years on mental health services, or an average annual increase of 3.4% and has equated the importance of mental health to the importance of physical health (Milne, 2019). Germany, which is consider to have one of the best mental health infrastructures in the world, has acted quickly to transfer services online. The government there has also reacted to correlations between Covid-19 related media consumption and symptoms of anxiety and depression (Bendau et al 2020) and elevated rates of depression and anxiety among young people. (Benke et al 2020) Access to Services Pre-Pandemic In Ireland, 25% of the population is affected by a mental health disorder at any one time (Condon, 2020). When it comes to accessibility of services, inequality is a major factor. The cost of treatment affects low income families who cannot afford private healthcare and must use understaffed and underfunded public services (EAPN, 2020). The healthcare system disproportionally supports those who can pay for private healthcare and does not give equal access to people based on needs.

Poverty is both a consequence of mental health issues and a catalyst for poor mental health, (Elliot, 2016). Even prior to the pandemic, there was an urgent need to address financial precarity and the scale of low wage work in Ireland, as well as the housing shortage. All of these issues have had a direct effect on mental health and on access to services. Mental health issues affect vulnerable groups in society, such as those who are unemployed or who cannot work due to illness or disability. The former have a consistent poverty rate of 27.6% and the latter, a consistent poverty rate of 21.3% (EAPN, 2020). Should their mental health decline, they cannot afford fast, accessible services.

Access to services reflects local levels of deprivation. For example, Dublin South West has a ratio of 35 inpatient beds per 100,000 in comparison to the HSE South Eastern area, which has a ratio of 235.8 beds per 100,000 (O’Shea & Kennely, 2008). There is also a shortage of rehabilitative services for high-risk individuals (O’Shea & Kennely, 2008).

The Pandemic and Mental Health The Irish COVID-19 Psychological Survey found that clinically meaningful levels of anxiety have increased by 20%, depression by 23%, post-traumatic stress by 18%, and loneliness by 41% due to the pandemic (Maynooth University, 2020). Over half the public (51.3%) reported that the COVID-19 pandemic has had a negative or very negative impact on their mental health and well-being generally (C19 RPC & Mental Health Reform, 2020). Another

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found that overall life satisfaction had “declined to 12.2% as opposed to 44.3% in 2018” (Karatzias, 2020 and Frawley, 2020).

Those most vulnerable to mental health issues at this time are front-line healthcare workers, those with pre-existing mental health struggles, those caught up in conflict or crisis, older people, young people, and adolescents (Osbourne, 2020). Healthcare workers, especially less experienced staff or students who have been fast-tracked into service, may be at greater risk of developing mental health issues. Even those not on the frontlines or non-clinical healthcare workers are in need of psychological support as they deal with the scale of the pandemic (National Health Library and Knowledge Service Evidence Team, 2020). Furthermore, medical practitioners have found an increase in mental illness relapses since the pandemic began (Gallagher, 2020). Out of those suffering from suicidal thoughts in Ireland, 45% attributed it to COVID-19 in some way (Ibid).

In relation to children’s mental health in particular, Barnardo’s found that even young children are feeling the toll on their mental health, as over half missed friends and school during the lockdown, 53% struggled with a bedtime routine, and 38% experienced more tantrums and outbursts (Osbourne, 2020).

Healthcare professionals face other immediate difficulties as well, with many of their resources and treatment strategies lost due to social distancing. A report by the psychiatric staff at St. John’s Hospital expressed concern for addiction patient’s constricted paths to recovery (Columb, 2020). Recovery is described as a biopsychosocial process, where a patient is meant to slowly transition back into society. But with both virtual treatment sessions and no social environment to reintegrate into, the path to recovery has become increasingly difficult.

Other concerns have been raised about youth mental health, as “resource allocation” for a virtual environment is lacking. According to a report by YoungMinds research, one in four young adults who had access to mental health support lost them during the pandemic (Power, 2020). Shutting down physical locations along with stay at home orders has disproportionately affected individuals who have lower incomes, live in rural areas, and those in abusive relationships. At two mental health facilities (Cluain Mhuire Mental Health Services in Dublin and Newcastle Mental Health Services in Wicklow), their face-to-face groups and outpatient services were cancelled (Lyne, 2020). While they did offer virtual meetings and other telemedicine approaches, there was an acknowledgement that strategies for care need to be developed for patients in rural areas or without access to the internet or phone services.

The increase of domestic violence and its immediate effect on mental health must also be addressed within the context of the pandemic. Safe Ireland (2020) reported an increase of 25% in calls to domestic services compared to 2018. They also found on average 7 requests for refuge per day could not be accommodated through traditional means due to a lack of services, however help was found through community aid (Ibid). The effects of domestic abuse and similar trauma tends to increase depression, anxiety, stress disorders, eating disorders, low self-esteem and suicidal thoughts, the majority of which are already heightened by the stress of COVID-19 (Safe Ireland: Get Help, 2020; Maynooth University, 4

2020). Children living in households where domestic violence is present may also struggle with their psychological wellbeing including depression, anxiety, learning difficulties and violent behaviour (Safe Ireland: Get Help, 2020).

Overall, the mental health and wellbeing of the country has declined as people feel a reduction in their sense of community, meaning and even privacy (Amarach Research, 2020). The largest decline has been in intimacy and emotional support. Amongst 18-24 year olds, 47% find this need unmet as a result of COVID-19 (Ibid).

Figure 1: Amarach Research, 2020: Comparison of wellbeing February 2019 against April 2020.

What has the Irish government done to support mental health during the pandemic?

Like other countries (e.g. Germany and France), Ireland’s mental healthcare system has made a shift to telemedicine and e-communication, and in person care that follows WHO guidelines (Fearon, 2020). But due to already present problems in the mental healthcare system, as well as inadequate resources to shift to an online format, Ireland faces a growing amount of challenges in the months ahead. One report suggests that the “psychosocial footprint” of the pandemic will be larger than the “medical footprint” (O’Conner, 2020).

The report emphasizes that the mental healthcare system is not prepared, as psychiatric facilities are understaffed and funding is lower than other European countries of comparable size. There have been subsequent appeals to have mandatory funding to increase National Clinical Programmes (NCPs) for mental health, which would improve access, quality, and cost of care. (Ibid) This decision is described as necessary for the Irish mental healthcare system to be prepared for a rapid increase in referrals to mental health facilities. With long waitlists for care already, the incoming rise in patients could cause immense stress to the system (Lyne, 2020).

Specifically, the Irish government and mental health organisations have done the following: created information on health and challenges posed in the pandemic, promoted connection 5

with others and coping mechanisms such as templates for returning to work, and the establishment of routines and tips to manage anxiety in the current situation. Financial supports such as the Pandemic Unemployment Payment, COVID-19 Business Loans and Short-time Work Support are in place to ease the burden brought on by the pandemic (Department of Business, Enterprise, and Innovation, 2020).

Going Forward ‘Sharing the Vision’ is the successor to ‘Vision for Change’ (2006-16). Even if fully funded, it could not have prepared for the mental health effects of the pandemic (Department of Health, 2020; O’Shea & Kennelly, 2008). The National Budget for 2021 has implemented the ‘Sharing the Vision’ framework. However, considering the depth of the crisis, another fullycosted multi-year plan needs to be considered.

The United Nations has outlined a 3 tier plan to respond to rise in mental health issues: 1) Apply a whole-of-society approach to promote, protect and care for mental health; 2) Ensure widespread availability of emergency mental health and psychosocial support; 3) Support recovery from COVID-19 by building mental health services for the future (United Nations, 2020).

The Irish College of Psychiatrists recommended the following this year in its pre-budget submission: an immediate increase of the Mental Health Services budget to a minimum 12% of the overall Health Service budget in 2021, separate to extra funding allocated each year for once off projects/capital expenditure; prioritization of mental health on par with physical health; increased funding for CAMHS (25% of overall budget); development of a mental health ICT system; more attention paid to the needs of the elderly and their carers; and a reinstatement of a national Mental Health Director and Division (College of Psychiatrists Ireland, 2020).

Drawing on the recommendations of both A Vision For Change and Sharing the Vision, should there also be greater investment in community-based services, specific models like social prescribing, and coordination with civil society? The government should continue to monitor the mental health impact through funding research and mechanisms for data collection, especially in relation to unequal access and quality of treatment.

References Amarach Research, (2020), Emotional Wellbeing in a Pandemic, available at: https://amarach.com/assets/files/mental-health-and-wellbeing-during-a-pandemic.pdf A Vision for Change, (2006), ‘Report of the expert group on mental health policy’, Government of Ireland.

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Action Mental Health, (2020), NI Affairs Committee hears local health spending is inequitable. [Online] Available at: https://www.amh.org.uk/news/ni-affairs-committeehears-local-health-spending-is-inequitable/ Banks, J. and Xu, X., (2020), The mental health effects of the first two months of lockdown and social distancing during the Covid-19 pandemic in the UK, s.l.: Institute for fiscal Studies.

Bendau, A., Petzold, M.B., Pyrkosch, L. et al. (2020). Associations between COVID-19 related media consumption and symptoms of anxiety, depression and COVID-19 related fear in the general population in Germany. Eur Arch Psychiatry Clin Neurosci. https://doi.org/10.1007/s00406-020-01171-6 Benke, C., Autenrieth, L. K., Asselmann, E., & Pané-Farré, C. A. (2020). Stay-at-home orders due to the COVID-19 pandemic are associated with elevated depression and anxiety in younger, but not older adults: results from a nationwide community sample of adults from Germany. Psychological medicine, 1–2. Advance online publication. https://doi.org/10.1017/S0033291720003438 C19 PRC and Mental Health Reform, (2020), ‘Responding to the mental health impact of COVID-19’, available at: https://www.mentalhealthreform.ie/wpcontent/uploads/2020/06/Responding-to-the-Mental-Health-Impact-of-COVID-19-ReportJuly-2020.pdf College of Psychiatrists Ireland, (2020), ‘Pre-Budget Submission 2021’, available at: https://www.irishpsychiatry.ie/wp-content/uploads/2020/10/CPsychI-2021-Pre-Budgetsubmission-final-09102020.pdf Condon, D, (2020), ‘Concern over mental health impact of COVID-19’, Irish Health, 19 May, available at: http://www.irishhealth.com/article.html?id=27221 Conlon, P, (2020), ‘Mental Health Charity Calls for Investment Policy in Budget 2021’, Dublin People, (13 October), available at: https://dublinpeople.com/news/northsideeast/articles/2020/10/13/mental-health-charitycalls-for-investment-policy-in-budget-2021/ [Accessed 6 November 2020].

Department of Business, Enterprise and Innovation, (2020), ‘Government supports for COVID-19 impact businesses.’ Dublin: Department of Business, Enterprise and Innovation, available at: https://dbei.gov.ie/en/What-We-Do/Supports-for-SMEs/COVID-19-supports/ Department of Health, (2020), ‘Sharing the Vision: A Mental Health Policy for Everyone’, available at: https://www.gov.ie/en/publication/2e46f-sharing-the-vision-a-mental-healthpolicy-for-everyone/ Department of Health, (2020), ‘Budget 2021: €4 billion to protect, reform and expand health and social care services and implement universal healthcare’, Dublin: Government of Ireland, Available at: https://www.gov.ie/en/press-release/3f618-budget-2021-4-billion-toprotect-reform-and-expand-health-and-social-care-services-and-implement-universalhealthcare/#:~:text=%22I%20am%20delighted%20today%20to,million%20to%20meet%20e xisting%20needs 7

EAPN Ireland, (2020), ‘Pre-Budget Submission 2021’, Available at: https://www.eapn.ie/wpcontent/uploads/2020/07/Pre-Budget-Submission-2021-EAPN-Ireland-final.pdf Elliott, I., (June 2016), Poverty and Mental Health: A review to inform the Joseph Rowntree Foundation’s Anti-Poverty Strategy, London: Mental Health Foundation Fearon, P., (2020), ‘Opening up while locking down: How an Irish independent sector mental health service is responding to the COVID-19 crisis’, Irish Journal of Psychological Medicine, 37(3), 172-177. doi:10.1017/ipm.2020.68 Gallagher, C., (2020). Ireland facing a 'tsunami' pf mental health problems. [Online] available at: https://www.irishtimes.com/news/health/ireland-facing-a-tsunami-of-mental-healthproblems-1.4273850 Karatzias T., Shevlin, M., Murphy, J., McBride, O., Ben-Ezra, M., Bentall, R.P., Vallieres, F., and Hyland, P., (2020), ‘Posttraumatic Stress Symptoms and Associated Comorbidity During the COVID-19 Pandemic in Ireland: A Population-Based Study’, available at: https://doi.org/10.1002/jts.22565 Lyne, J., Roche, E., Kamali, M., and Feeney, L., (2020). ‘COVID-19 from the perspective of urban and rural general adult mental health services.’ Irish Journal of Psychological Medicine, 37(3), 181-186. doi:10.1017/ipm.2020.62 Mental Health Reform, (2018), ‘Public Attitudes to Investment in Mental Health Services’, available at: https://www.mentalhealthreform.ie/wp-content/uploads/2018/10/PublicAttitudes-to-Investment-in-Mental-Health-Services-MHR-IPSOS-October-2018.pdf Mental Health Reform, (2020), ‘Pre-Budget Submission 2021’, available at: https://www.mentalhealthreform.ie/wp-content/uploads/2020/08/Mental-Health-ReformPre-Budget-Submission-2021-Final.pdf National Health Library and Knowledge Service Evidence Team, (2020), ‘What psychological supports are required to assist health workers during the COVID-19 pandemic?’ available at: https://hselibrary.ie/what-psychological-supports-are-required-to-assist-health-workersduring-the-covid-19-pandemic/ O’Connor, K., Wrigley, M., Jennings, R., Hill, M., and Niazi, A., (2020), ‘Mental health impacts of COVID-19 in Ireland and the need for a secondary care mental health service response.’

Irish Journal of Psychological Medicine, 1-9. doi:10.1017/ipm.2020.64 Maynooth University, (2020), Irish COVID-19 Psychological Survey, available at: https://www.maynoothuniversity.ie/news-events/covid-19-mental-health-surveymaynooth-university-and-trinity-college-finds-high-rates-anxiety McDaid, S., (2020), Government must plan for mental health recovery from COVID-19.

[Online] available at: https://www.alustforlife.com/the-bigger-picture/government-mustplan-for-mental-health-recovery-from-covid-19

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Milne, C., (2019). Mental health spending in the English NHS. [Online] available at: https://fullfact.org/health/mental-health-spending-england/ Osbourne, B., (2020), ‘Significant Impact of Covid 19 on mental health’, Irish Medical Times, Available at: https://www.imt.ie/features-opinion/significant-impact-covid-19-mentalhealth-10-06-2020/ O'Shea, E. and Kennelly, B., (2008), The Economics of Mental Health Care in Ireland, Galway: Mental Health Commission.

Rural Health Information Hub, (2010), ‘Factors that Impact Mental Health in Rural Areas’, Available at: https://www.ruralhealthinfo.org/toolkits/mental-health/1/outside-factors Safe Ireland, (2020), ‘Nearly 3,500 women contacted a domestic service for the first time during initial lockdown’, SafeIreland, available at:https://www.safeireland.ie/nearly-3500women-contacted-a-domestic-violence-service-for-the-first-time-during-initial-lockdownnew-safe-ireland-report-on-covid-19/ Safe Ireland: Get Help, (2020), ‘Impact of Domestic Violence’, SafeIreland, available at: https://www.safeireland.ie/get-help/understanding-domestic-abuse/impact-of-domesticviolence/ ‘The Irish Times view on mental health funding: a chance to improve.’ 2018. The Irish Times, 15 October,[Online] available at: https://www.irishtimes.com/opinion/editorial/the-irishtimes-view-on-mental-health-funding-a-chance-to-improve-1.3663451 United Nations, (2020), ‘Policy Brief: COVID-19 and the Need for Action on Mental Health’, (13 May), available at: https://unsdg.un.org/sites/default/files/2020-05/UN-Policy-BriefCOVID-19-and-mental-health.pdf

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